Cell-surface residence of sphingosine 1-phosphate receptor 1 on lymphocytes determines lymphocyte egress kinetics

The sphingosine 1-phosphate receptor 1 (S1P₁) promotes lymphocyte egress from lymphoid organs. Previous work showed that agonist-induced internalization of this G protein–coupled receptor correlates with inhibition of lymphocyte egress and results in lymphopenia. However, it is unclear if S1P₁ internalization is necessary for this effect. We characterize a knockin mouse (S1p1r^S5A/S5A) in which the C-terminal serine-rich S1P₁ motif, which is important for S1P₁ internalization but dispensable for S1P₁ signaling, is mutated. T cells expressing the mutant S1P₁ showed delayed S1P₁ internalization and defective desensitization after agonist stimulation. Mutant mice exhibited significantly delayed lymphopenia after S1P₁ agonist administration or disruption of the vascular S1P gradient. Adoptive transfer experiments demonstrated that mutant S1P₁ expression in lymphocytes, rather than endothelial cells, facilitated this delay in lymphopenia. Thus, cell-surface residency of S1P₁ on T cells is a primary determinant of lymphocyte egress kinetics in vivo.Sphingosine 1-phosphate (S1P), a multifunctional lipid mediator that signals via five G protein–coupled receptors (GPCRs), regulates vascular maturation, permeability, and angiogenesis (Hla, 2004; Cyster, 2005). Recently, interest in the roles of S1P and its receptors in the immune system has been prompted in part by the identification of the immunomodulator FTY720 (Brinkmann et al., 2002; Mandala et al., 2002; Chiba, 2005), which upon phosphorylation by Sphk2 to FTY720-P (Sanchez et al., 2003; Zemann et al., 2006) acts as a strong agonist for four out of five S1P receptors (Brinkmann et al., 2004). FTY720 induces profound lymphopenia by inhibiting the egress of lymphocytes from the thymus, peripheral lymph nodes, and Peyer’s patches (Chiba, 2005). Indeed, it is now appreciated that S1P signaling modulates the trafficking of not only naive and central memory T cells, but also B cells, dendritic cells, NK cells, osteoclasts, and hematopoietic progenitor cells (Allende and Proia, 2002; Kabashima et al., 2006; Massberg et al., 2007; Schwab and Cyster, 2007; Walzer et al., 2007; Ledgerwood et al., 2008; Rivera et al., 2008; Sebzda et al., 2008; Ishii et al., 2009). These studies suggest that S1P regulates hematopoietic and immune cell trafficking under homeostatic and disease conditions; however, it is unclear precisely how S1P receptor signaling modulates cellular responses to egress cues.The mechanism of how S1P regulates T cell trafficking has been intensively investigated; T cell–specific deletion of S1p1r or hematopoietic reconstitution using S1p1r^−/− fetal liver cells resulted in profound lymphopenia, suggesting that the T cell–intrinsic S1P receptor 1 (S1P₁) is essential for their egress from the thymus and secondary lymph nodes (Allende et al., 2004; Matloubian et al., 2004). This observation, coupled with the finding that FTY720-P induces the loss of cell-surface S1P₁ from lymphocytes in an irreversible manner (Gräler and Goetzl, 2004; Matloubian et al., 2004), suggests that functional antagonism of S1P₁ in the lymphocyte compartment is essential for the inhibition of T cell egress.However, other studies have led to the proposal of an alternative mechanism by which S1P₁ regulates lymphocyte egress. Immunofluorescence microscopy demonstrated high expression levels of S1P₁ in endothelial cells, whereas staining of lymphocytes was weaker (Singer et al., 2005; Sinha et al., 2009). Moreover, administration of SEW2971, a selective S1P₁ agonist, does not induce irreversible receptor loss from the cell surface but causes significant lymphopenia in vivo (Jo et al., 2005). Two-photon microscopy of explanted lymph nodes containing labeled lymphocytes suggested that S1P₁ agonists may modulate barrier function and closure of vascular portals in the medulla, through which T cells egress into efferent lymphatics (Wei et al., 2005). Thus, this alternative proposal favors endothelial cells as the primary target cell type for S1P₁ agonists to inhibit lymphocyte egress (Rosen et al., 2008).Close interactions between immune and vascular cells may underlie the ability of S1P₁ to promote lymphocyte egress. In lymph node cortical sinuses, egress of T and B cells required S1P₁-dependent transendothelial traverse (Grigorova et al., 2009; Sinha et al., 2009). Indeed, competing chemotactic signaling between the egress-promoting S1P–S1P₁ system and the retention-promoting CXCL21–CCR7 chemokine receptor system of T cells appears to determine the rate and extent of their egress from secondary lymphoid organs (Pham et al., 2008). Whether S1P₁ signaling in lymphocytes, endothelial compartments, or both is important in the process of egress is not known.S1P₁ is a type I GPCR that is rapidly phosphorylated upon agonist stimulation. Although several protein kinases are involved in the phosphorylation of S1P₁ (Lee et al., 2001), phosphorylation at the C-terminal domain is particularly relevant to receptor desensitization and internalization (Hla, 2001). Because FTY720-P is degraded less efficiently than S1P by S1P lyase and S1P phosphatases (Bandhuvula et al., 2005; Mechtcheriakova et al., 2007; Yamanaka et al., 2008), its ligation likely induces sustained receptor activation kinetics. Presumably, this underlies the FTY720-P–induced irreversible internalization and proteosomal degradation of S1P₁ and resultant lymphopenia (Oo et al., 2007). The GRK-2 enzyme is capable of phosphorylating the serine-rich motif in the C-terminal tail of S1P₁ (Watterson et al., 2002), and we recently demonstrated that mutation of the five serines in the C terminus of S1P₁ to nonphosphorylatable alanines inhibited S1P- and FTY720-P–induced receptor internalization in transfected HEK293 cells (Oo et al., 2007). Although previous studies of GPCR signaling and chemotaxis have provided some insights into the role of internalization in these processes, the results appear to be receptor specific. For example, a CXCR4 superagonist induced greater chemotaxis than the native ligand stromal cell–derived factor–1α (SDF-1α) with no perceptible receptor internalization (Sachpatzidis et al., 2003). Conversely, mutations in the C terminus of CXCR2 resulted in defective receptor internalization concomitant with impaired chemotaxis (Sachpatzidis et al., 2003). In the case of S1P₁, it is unknown whether internalization is required for lymphocyte egress and recirculation.To address the role of S1P₁ internalization in the control of lymphocyte egress during homeostasis and FTY720 treatment, we developed a mouse model in which WT S1P₁ is replaced by the internalization-deficient mutant (S5A-S1P₁). We show that although T cell trafficking under homeostasis is unaltered, S1p1r^S5A/S5A mice display kinetic resistance to lymphopenia induced by the S1P₁ modulator (FTY720-P) or disruption of the S1P gradient. Adoptive transfer of S1p1r^WT/WT and S1p1r^S5A/S5A lymphocytes and S1P₁ surface staining of lymph node endothelial cells demonstrate that the T cell S1P₁, and not endothelial cell S1P₁ expression, regulates the rate of lymphocyte egress in vivo. These data support a T cell–intrinsic model of S1P₁ signaling in egress kinetics wherein the internalization of S1P₁ is a crucial modulator of the cues for T cell migration.     

Premature Ticagrelor Discontinuation in Secondary Prevention of Atherosclerotic CVD: JACC Review Topic of the Week

Ticagrelor is a cornerstone of modern antithrombotic therapy alongside aspirin in patients with acute coronary syndrome and after percutaneous coronary intervention. Adverse effects such as bleeding and dyspnea have been associated with premature ticagrelor discontinuation, which may limit any potential advantage of ticagrelor over clopidogrel. The randomized trials of ticagrelor captured adverse events, offering the opportunity to more precisely quantify these effects across studies. Therefore, a meta-analysis of 4 randomized clinical trials of ticagrelor conducted between January 2007 and June 2017 was performed to quantify the incidence and causes of premature ticagrelor discontinuation. Among 66,870 patients followed for a median 18 months, premature ticagrelor discontinuation was seen in 25%; bleeding was the most common cause of discontinuation followed by dyspnea. Versus the comparators, the relative risk of dyspnea-related discontinuation during follow-up was 6.4-fold higher, the relative risk of bleeding was 3.2-fold higher, and the relative risk of discontinuation due to any adverse event was 59% higher for patients receiving ticagrelor. Understanding these potential barriers to adherence to ticagrelor is crucial for informed patient-physician decision making and can inform future efforts to improve ticagrelor adherence. This review discusses the incidence, causes, and biological mechanisms of ticagrelor-related adverse effects and offers strategies to improve adherence to ticagrelor.     

Cocaine-induced methemoglobinemia

Dear editor,We congratulate Chowdhury et al[1] for their excellentreport and successful management of a young ladysuffering from cocaine-induced methemoglobinemia.Through this letter, we aim to address some additionalconcerns, which would certainly be helpful for acomplete understanding of this topic.     

Risk Factors for Wound Infections after Vascular Surgery: Kuwait Experience

IntroductionWound infections represent a serious complication after vascular surgery particularly after vascular reconstructive procedures. We aimed to identify risk factors predisposing patients to these complications.MethodsThis was a retrospective review of open vascular surgical procedures performed between April 2014 and March 2019 in Kuwait. Patient demographics, procedures performed and their indications, and post-operative outcomes were collected and analyzed. Patients with pre-operative active infections were excluded from the analysis. Statistical analysis was performed, and odds ratios (ORs) and relative risks were calculated for the outcomes of interest. Fisher''s exact test and two-tailed t test were used where appropriate.Results391 patients were identified. The majority (54%) presented with chronic limb threatening ischemia. The mean age was 58 (±10) years, with a male predominance (76%). Wound infection occurred in 53 (14%) patients. The most commonly isolated organism was Staphylococcus aureus (47%). Diabetes (OR 8.03, 95% CI: 1.9142–33.7439, p = 0.0044), hypertension (OR 2.38, 95% CI: 1.2960–4.3684, p = 0.0052), ischemic heart disease (OR 2.30, 95% CI: 1.4349–4.6987, p = 0.0016), hyperlipidemia (OR 2.12, 95% CI: 1.0305–4.3620, p = 0.0412), and chronic renal failure (OR 2.55, 95% CI: 1.0181–6.4115, p = 0.0457) were all found to be significantly associated with the development of post-operative wound infections in vascular surgery patients.ConclusionDiabetes, hypertension, ischemic heart disease, hyperlipidemia, and chronic renal failure were associated with post-operative wound infections. Anticipation of wound complications in patients with these risk factors may aid early diagnosis and treatment.     

Paediatric gastrointestinal disorders in SARS-CoV-2 infection: Epidemiological and clinical implications

The coronavirus disease 2019 (COVID-19) pandemic is a threat worldwide for individuals of all ages, including children. Gastrointestinal manifestations could be the initial presenting manifestation in many patients, especially in children. These symptoms are more common in patients with severe disease than in patients with non-severe disease. Approximately 48.1% of patients had a stool sample that was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral RNA. Children typically form 1%-8% of all laboratory-confirmed cases of SARS-CoV-2. Gastrointestinal manifestations of COVID-19 in children are not rare, with a prevalence between 0 and 88%, and a wide variety of presentations, including diarrhoea, vomiting, and abdominal pain, can develop before, with or after the development of respiratory symptoms. Atypical manifestations such as appendicitis or liver injury could also appear, especially in the presence of multisystem inflammatory disease. In this review, we discussed the epidemiology of COVID-19 gastrointestinal diseases in children as well as their implications on the diagnosis, misdiagnosis, prognosis, and faecal-oral transmission route of COVID-19 and the impact of gastrointestinal diseases on the gut microbiome, child nutrition, and disease management.     

Progression of fibrosis in hepatitis C with and without schistosomiasis: correlation with serum markers of fibrosis

Serial liver biopsies are the gold standard by which the progression of fibrosis is evaluated. This longitudinal cohort study assessed the different rates in the progression of fibrosis using serial liver biopsies and serum fibrosis markers YKL-40 and PIIINP and the cytokines, transforming growth factor beta (TGF-beta) and tumor necrosis factor alpha (TNuF-alpha). A 10-year cohort study was performed in patients with hepatitis C virus (HCV) alone or HCV and schistosomiasis. Patients were enrolled at the time of acute HCV infection and prospectively evaluated with two liver biopsies (at entry and end of follow-up), and true rates in the progression of fibrosis were calculated per year. Serum YKL-40, N-terminal propeptide of collagen III (PIIINP), TGF-beta, and TNF-alpha were measured, as well as the expression of TGF-beta, TNF-alpha, and YKL-40 mRNA in liver tissue. A significant increase in the progression rates of fibrosis occurred in the coinfected group (0.61 +/- 0.13) compared with the HCV monoinfection group (0.1 +/- 0.06; P < .001)). The progression of fibrosis rate/year had a direct linear correlation for YKL-40 (r = 0.892, P < .001) and for PIIINP (r = 0.577, P < .01). YKL-40 showed a linear correlation with TGF-beta (r = 0.897, P < .001). Hepatic mRNA levels of YKL-40 and TGF-beta correlated with the serum levels, confirming a hepatic source for the elevated serum levels. In conclusion, serial cytokine and fibrosis markers can accurately determine the rate at which fibrosis is progressing, identifying both those with rapid fibrosis and those with stable disease.     

Basaloid squamous carcinoma metastatic to renal-cell carcinoma: Fine-needle aspiration cytology of tumor-to-tumor metastasis

We describe an unusual case of a basaloid squamous-cell carcinoma (BSCC) of the tonsil in a 56-yr-old man that metastasized to a primary renal-cell carcinoma (RCC) and the lung. The diagnosis of the second primary, the RCC, was based on fine-needle aspiration (FNA) cytology. A subsequent nephrectomy specimen revealed BSCC metastatic to RCC, clear-cell type. Retrospective analysis of the FNA of the renal mass revealed classic RCC morphology and, in addition, another cytologically distinctive pattern characterized by occasional sheets of cohesive neoplastic cells with hyperchromatic nuclei and nuclear molding representative of BSCC. The cytologic features of a subsequent FNA of the lung were characteristic of metastatic BSCC. Our retrospective analysis of cytologic material from the renal mass underscores the importance of raising the possibility of tumor-to-tumor metastasis when distinctly different morphologic features are seen in an otherwise typical cytology of a neoplasm in patients with an already known or suspected second primary. To our knowledge, this case report is the first one documenting metastasis of BSCC to RCC. Diagn. Cytopathol. 1997;17:379–382. © 1997 Wiley-Liss, Inc.     

Tofacitinib, a Janus Kinase Inhibitor Demonstrates Efficacy in an IL-15 Transgenic Mouse Model that Recapitulates Pathologic Manifestations of Celiac Disease

Celiac disease (CD) is an immune-mediated, inflammatory disorder of the small intestines with a defined genetic etiological component associated with the expression of HLA-DQ2 and/or HLA-DQ8 haplotypes. The dietary consumption of gluten-rich cereals triggers a gluten-specific immune response in genetically susceptible individuals leading to a spectrum of clinical manifestations ranging from an inapparent subclinical disease, to overt enteropathy that can in some individuals progress to enteropathy-associated T cell lymphoma (EATL). The tissue-destructive pathologic process of CD is driven by activated NK-like intraepithelial CD8⁺ lymphocytes and the proinflammatory cytokine IL-15 has emerged to be pivotal in orchestrating this perpetual tissue destruction and inflammation. Moreover, transgenic mice that over-express human IL-15 from an enterocyte-specific promoter (T3^b-hIL-15 Tg) recapitulate many of the disease-defining T and B cell-mediated pathologic features of CD, further supporting the evolving consensus that IL-15 represents a valuable target in devising therapeutic interventions against the form of the disease that is especially refractory to gluten-free diet. In the present study, we evaluated the potential efficacy of tofacitinib, a pan-JAK inhibitor that abrogates IL-15 signaling, as a therapeutic modality against CD using T3^b-hIL-15 Tg mice. We demonstrate that tofacitinib therapy leads to a lasting reversal of pathologic manifestations in the treated mice, thereby highlighting the potential value of tofacitininb as a therapeutic modality against refractory CD for which no effective therapy exists currently. Additionally, the visceral adiposity observed in the tofacitinib-treated mice underscores the importance of continued evaluation of the drug’s impact on the lipid metabolism.     

Use of Antibodies in Lymphocyte Secretions for Detection of Subclinical Tuberculosis Infection in Asymptomatic Contacts

We have previously demonstrated that Mycobacterium bovis BCG-specific immunoglobulin G antibodies in lymphocyte secretions (ALS) can be employed as a marker for active tuberculosis (TB). We aimed to determine whether the ALS method allows detection of subclinical TB infection in asymptomatic individuals. A prospective study of family contacts (FCs) of patients with active TB and healthy controls was performed. Thirteen of 42 FCs had high ALS responses, including 6 FCs who subsequently developed active TB. No correlation was observed between the tuberculin skin test and the ALS responses in the FCs (r = 0.1, P = 0.23). Among patients with active TB, BCG-specific ALS responses steadily declined from the time of diagnosis through 6 months following antimycobacterial chemotherapy (P = 0.001). The ALS assay enabled detection of infection in exposed symptom-free contacts, who are at greater risk for developing active TB. The method may also allow discrimination between effective treatment of active infection and suboptimal response to therapy.